<input type="hidden" name="is_practicioner" id="is_practicioner" value="1">
<ul class="main-two-cols">
	<li class="two-cols-left">
		<h2 class="singlerow">USER DETAILS</h2>
		<ul class="rows">
			<li class="leftcol">Name</li>
			<li class="rightcol">
				<input type="text" name="name" id="name" value="<?=$details_row['name']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Address</li>
			<li class="rightcol">
				<textarea name="address" id="address"><?=$details_row['address']?></textarea>
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">City/Suburb</li>
			<li class="rightcol">
				<input type="text" name="city" id="city" style="width:100px" value="<?=$details_row['city']?>">&nbsp;&nbsp;
				Zipcode 
				<input type="text" name="zipcode" id="zipcode" style="width:50px" value="<?=$details_row['zipcode']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Phone No.</li>
			<li class="rightcol">
				<input type="text" name="phone" id="phone" value="<?=$details_row['phone']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Fax No.</li>
			<li class="rightcol">
				<input type="text" name="fax" id="fax" value="<?=$details_row['fax']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Prescriber No.</li>
			<li class="rightcol">
				<input type="text" name="presciber_no" id="presciber_no" value="<?=$details_row['presciber_no']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Provider No.</li>
			<li class="rightcol">
				<input type="text" name="provider_no" id="provider_no" value="<?=$details_row['provider_no']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">HPI-I No.</li>
			<li class="rightcol">
				<input type="text" name="hpi_i_no" id="hpi_i_no" value="<?=$details_row['hpi_i_no']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">State Registration No.</li>
			<li class="rightcol">
				<input type="text" name="state_reg_no" id="state_reg_no" value="<?=$details_row['state_reg_no']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Qualifications</li>
			<li class="rightcol">
				<textarea name="qualification" id="qualification" style="height:100px;"><?=$details_row['qualification']?></textarea>
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Email</li>
			<li class="rightcol">
				<input type="text" name="email" id="email" value="<?=$details_row['email']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Status</li>
			<li class="rightcol">
				<input type="radio" name="status" value="presciber" <?=($details_row['status'] == "presciber")?'checked':''?>> Prescriber &nbsp;
				<input type="radio" name="status" value="locum" <?=($details_row['status'] == "locum")?'checked':''?>> Locum				
			</li>
		</ul>
	</li>

	<li class="two-cols-right">
		<h2 class="singlerow">PCEHR DETAILS</h2>
		<ul class="rows">
			<li class="leftcol">Title</li>
			<li class="rightcol">
				<input type="text" name="pcehr_title" id="pcehr_title" value="<?=$details_row['pcehr_title']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">First Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_fname" id="pcehr_fname" value="<?=$details_row['pcehr_fname']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Middle Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_mname" id="pcehr_mname" value="<?=$details_row['pcehr_mname']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Last Name</li>
			<li class="rightcol">
				<input type="text" name="pcehr_lname" id="pcehr_lname" value="<?=$details_row['pcehr_lname']?>" >
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">&nbsp;</li>
			<li class="rightcol">
				<input type="checkbox" name="pcehr_check" id="pcehr_check" value="1" <?=($details_row['pcehr_check'] == 1)?'checked':''?> >
				Check patients PCEHR status as you open their record
			</li>
		</ul>

		<br clear="all" />

		<h2 class="singlerow">EPRESCRIBING</h2>
		<ul class="rows">
			<li class="leftcol">Status</li>
			<li class="rightcol">
				<input type="text" name="eprescibing_status" id="eprescibing_status" value="<?=$details_row['eprescibing_status']?>">
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">&nbsp;</li>
			<li class="rightcol">
				<input type="radio" name="eprescribing_disable" value="0" <?=($details_row['eprescribing_disable'] == 0)?'checked':''?> > Enable ePrescibing<br/>
				<p id="enable-eprescribing" style="margin-left:20px; display:none">
					<input type="checkbox" name="eprescribing_enable_ask" id="eprescribing_enable_ask" value="1" <?=($details_row['eprescribing_enable_ask'] == 1)?'checked':''?> > Receive dispense notification - Ask patient<br/>
					<input type="checkbox" name="eprescribing_enable_dont_ask" id="eprescribing_enable_dont_ask" value="1" <?=($details_row['eprescribing_enable_dont_ask'] == 1)?'checked':''?> > Receive dispense notification - Do not ask patient
				</p>
				<input type="radio" name="eprescribing_disable" value="1" <?=($details_row['eprescribing_disable'] == 1)?'checked':''?> > Disable ePrescribing
			</li>
		</ul>
		<ul class="rows">
			<li class="leftcol">Others</li>
			<li class="rightcol">
				<input type="checkbox" name="top_level_access" id="top_level_access" value="1" <?=($details_row['top_level_access'] == 1)?'checked':''?> > Top Level Access<br/>
				<input type="checkbox" name="pki_encryption" id="pki_encryption" value="1" <?=($details_row['pki_encryption'] == 1)?'checked':''?> > PKI Encryption <br/>
				<input type="checkbox" name="data_export" id="data_export" value="1" <?=($details_row['data_export'] == 1)?'checked':''?> > Data Export Priveledge<br/>
				<input type="checkbox" name="auto_capitalizing" id="auto_capitalizing" value="1" <?=($details_row['auto_capitalizing'] == 1)?'checked':''?> > Auto capitalize names<br/>
				<input type="checkbox" name="option_edition" id="option_edition" value="1" <?=($details_row['option_edition'] == 1)?'checked':''?>> Options for editing<br/>
			</li>
		</ul>
	</li>
</ul>

<script type="text/javascript">
	$( document ).ready(function() {
		$('input[name="eprescribing_disable"]').on('change', function(){
		    if ($(this).val() == 0) {
		        $("#enable-eprescribing").show();
		    } else  {
		        $("#enable-eprescribing").hide();
		    }
		});
	});
</script>